Silver Simple- HSA - 58081GA0010029 Health Insurance Plan
Oscar Health Plan of Georgia health insurance plan with the Plan ID 58081GA0010029. The plan is called Silver Simple- HSA.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.80% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.20% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 58081GA0010029 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Georgia | ||||||||||||||||||
| Health Insurance Issuer | Oscar Health Plan of Georgia | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 58081GA0010029-00 | ||||||||||||||||||
| Provider Network(s) | ['GAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 58081GA0010029-00 Standard On Exchange Plan - 58081GA0010029-01 Open to Indians below 300% FPL - 58081GA0010029-02 Open to Indians above 300% FPL - 58081GA0010029-03 73% AV Silver Plan - 58081GA0010029-04 |
||||||||||||||||||
| Last Plan Update Date | Wed, 01 Mar 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Silver Simple- HSA Health Insurance Plan, 58081GA0010029-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $0.00 Copay after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00 Copay after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
YES | $0.00 Copay after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | $0.00 Copay after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Procedure(s) per Year |
NO | ||
| Diabetes Education
|
YES | $0.00 Copay after deductible |
100.00% |
| Dialysis
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $0.00 Copay after deductible |
$0.00 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | $0.00 Copay after deductible |
$0.00 Copay after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
YES | $0.00 Copay after deductible |
100.00% |
| Generic Drugs
Deductible waived for Oscar?s HSA preventive drug list. |
YES | Tier 1: $0.00 Copay after deductible Tier 2: $0.00 Copay after deductible |
100.00% |
| Habilitation Services
Limit: 40.0 Visit(s) per Year Habilitative services apply toward the 'Physical medicine and rehabilitative services' maximum number of visits specified in the 'Schedule of Benefits'. |
YES | $0.00 Copay after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 120.0 Visit(s) per Year |
YES | $0.00 Copay after deductible |
100.00% |
| Hospice Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $0.00 Copay after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Insulin infusion devices. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00 Copay after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: $0.00 Copay after deductible Tier 2: $0.00 Copay after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | $0.00 Copay after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00 Copay after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $0.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year |
YES | $0.00 Copay after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Only covers orthodontic treatment for a congenital anomaly related to or developed as a result of cleft palate, with or without cleft lip. |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00 Copay after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00 Copay after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 40.0 Visit(s) per Year |
YES | $0.00 Copay after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00 Copay after deductible |
100.00% |
| Preferred Brand Drugs
Deductible waived for Oscar?s HSA preventive drug list. |
YES | $0.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | $0.00 |
100.00% |
| Preventive Care/Screening/Immunization
The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC). |
YES | $0.00 |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00 Copay after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | $0.00 Copay after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year |
YES | $0.00 Copay after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year |
YES | $0.00 Copay after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00 Copay after deductible |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $0.00 Copay after deductible |
100.00% |
| Specialty Drugs
|
YES | $0.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $0.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00 Copay after deductible |
100.00% |
| Transplant
Limit: 10000.0 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant. |
YES | $0.00 Copay after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00 Copay after deductible |
100.00% |
| Weight Loss Programs
Limit: 4.0 Visit(s) per Year Nutritional counseling for the treatment of obesity, which includes morbid obesity. |
YES | 100.00% | |
| Well Baby Visits and Care
Care provided for birth through age 5. |
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00 Copay after deductible |
100.00% |
Silver Simple- HSA Health Insurance Plan Variant 58081GA0010029-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.717973896 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 20% |
| Formulary ID | GAF001 |
| Formulary URL | URL |
| HIOS Product ID | 58081GA001 |
| Import Date | 3/1/2023 1:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 58081 |
| Issuer Marketplace Marketing Name | Oscar Health Plan of Georgia |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | GAN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency and Urgent Services only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 58081GA0010029-00 |
| Plan Marketing Name | Silver Simple- HSA |
| Plan Type | HMO |
| Plan Variant Marketing Name | Silver Simple- HSA |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $4,850 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $4,850 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | GAS001 |
| Source Name | HIOS |
| Plan ID | 58081GA0010029 |
| State Code | GA |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $9700 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4850 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,850 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $9700 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $4850 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $4,850 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $9700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $4850 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,850 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $9700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $4850 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $4,850 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Silver Simple- HSA Health Insurance Plan, 58081GA0010029
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver Simple- HSA, 58081GA0010029 Health Insurance Plan, 58081GA0010029
-
Does Silver Simple- HSA Health Insurance Plan, 58081GA0010029 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58081GA0010029) Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs?
Does (58081GA0010029) Health Insurance Plan, Variant (58081GA0010029-00) have Out Of Country Coverage?
Does (58081GA0010029) Health Insurance Plan, Variant (58081GA0010029-00) have Out of Service Area Coverage?
Does (58081GA0010029) Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs?
Does Silver Simple- HSA Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs for Asthma?
Does Silver Simple- HSA Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs for Heart disease?
Does Silver Simple- HSA Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs for Depression?
Does Silver Simple- HSA Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs for Diabetes?
Does Silver Simple- HSA Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Silver Simple- HSA Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs for Low back pain?
Does Silver Simple- HSA Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs for Pregnancy?
Does Silver Simple- HSA Health Insurance Plan, Variant (58081GA0010029-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API